Archived: Beech Hall

We found the following examples of good practice.

The premises were very clean and well-maintained. Beech Hall had a cleaning schedule in place for staff to follow to ensure good infection control was maintained.

Staff had received training in infection prevention and control, including how to put on and take off their personal protective equipment (PPE) in a safe and effective way.

We saw staff wore PPE as appropriate, and regularly washed and sanitised their hands. The home supported staff around uniforms. These were washed and kept at the service to minimise cross contamination.

Tests for COVID-19 were being carried out in line with good practice guidance, where possible.

We observed good signage around the home in relation to COVID-19 with Sunflowers on people’s rooms who were isolating including dates of when isolation commenced and ended.

Visits to the home were restricted at the time of this inspection, in accordance with local infection control guidance. Staff were supporting people to stay in contact with their relatives via telephone calls, letters or via on-line video calls.

Staff we spoke with were passionate about their role and commended the registered manager on how well they had been supported throughout the COVID-19 period. One staff member said, "We have worked so hard. It has been hard. [Name of registered manager] has been amazing checking up on us all inside and outside of work.”

Further information is in the detailed findings below.

Beech Hall is a residential care home providing personal care for up to 64 people aged 65 and over, many of whom live with dementia. At the time of the inspection 64 people were using the service. The home consists of purpose built accommodation spread across three floors. Two of these floors have been specially adapted to meet the needs of people living with dementia.

People’s experience of using this service and what we found

People received extremely kind and compassionate care from staff who were dedicated in making people’s lives as comfortable as possible. Staff had developed extremely strong relationships with people and used information on people’s past lives and preferences to plan and deliver highly person-centred care. People were fully involved in the service, having real influence over all aspects of their care and how the home operated. The service was highly effective at promoting people’s independence.

The service had developed exceptionally strong links with the local community to the benefit of people who used the service. People had access to an excellent variety of activities and staff engaged with them at every opportunity. People, relatives and health professionals all said the service provided exceptional care. People’s individual needs and preferences were fully catered for, taking into account their equality characteristics. The service provided highly personalised and compassionate end of life care.

The registered manager had ensured a highly person-centred culture within the home with all groups of staff dedicated to ensuring people’s needs were fully met. People, relatives and staff provided excellent feedback about the management team. The service had significantly improved over the past few years and was constantly looking at ways to further improve. The service was a positive example to others and worked with a number of organisations to develop and share best practice.

The service was safe. Risks to people’s health and safety were assessed and detailed risk assessments put in place for staff to follow. People received their medicines safely and as prescribed. The premises were safe and regularly checked. There were enough staff to ensure people received a high level of care.

People received effective care from staff with the right skills and knowledge to care for them. People were provided with a variety of food and drink that met their individual needs. The service liaised well with health professionals to ensure people’s healthcare needs were met. People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible and in their best interests; the policies and systems in the service supported this practice. The service provided high quality, person-centred dementia care.

For more details, please see the full report which is on the CQC website at www.cqc.org.uk

Rating at last inspection

The last rating for this service was requires improvement (published 19 January 2018). There was also an inspection on 17 August 2018 however, the report following that inspection was withdrawn as there was an issue with some of the information that we gathered.

Why we inspected

This is a planned re-inspection because of the issue highlighted above.

Follow up

We will continue to monitor information we receive about the service until we return to visit as per our re-inspection programme. If we receive any concerning information we may inspect sooner.

We undertook this focused inspection to check the required improvements had been made and to confirm that the location now met legal requirements. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Beech Hall on our website at www.cqc.org.uk

Beech Hall is registered to provide accommodation for up to 64 people requiring nursing or personal care. Beech Hall is purpose built and is located in the Armley area of Leeds. At the time of our inspection there were 58 people living at the home.

The service had a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had made improvements to the ensure safety checks of the environment and equipment were completed in a timely manner. Also they had ensured that where actions were identified these were carried out. However, we found that further improvements were required in relation to record keeping.

People told us they felt safe and staff were clear about their responsibilities in relation to protecting people from avoidable harm or abuse. Records showed that risks were identified and managed safely. Accidents and incidents were dealt with appropriately and monitored by the provider.

There were safe medicine management systems in place.

The provider carried out appropriate background checks before employing staff, and we found they were deployed in sufficient numbers to provide care and support safely.

The majority of people and staff we spoke with were complimentary about the registered manager and management team. However, we did receive some feedback about areas that could improve.

Beech Hall is registered to provide accommodation for up to 64 people requiring nursing or personal care. Beech Hall is purpose built and is located in the Armley area of Leeds. Accommodation is over three floors. The top floor can accommodate up to 25 people, the middle floor 23 people and the ground floor up to 16 people. Each floor has single bedrooms which have en-suite facilities. There are communal bathrooms throughout the home. Each floor has an open plan communal lounge and dining room. The home has a lift to access all floors and has car parking to the front of the building. There is a selection of communal rooms throughout the building.

At the time of this inspection the home had a registered manager who had been in post since February 2017. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Before the inspection we received a notification of an incident at Beech Hall that occured prior to the current provider’s registration. Following the incident a service user sustained a serious injury. The incident is subject to a criminal investigation and as a result of these considerations, this inspection did not examine the circumstances of the incident. However, the information shared with CQC about the incident indicated potential concerns about the management and safety of equipment and staffing levels. This inspection examined those risks.

We identified a number of concerns relating to fire safety. This included daily fire safety checks not being carried out, failure to maintain equipment and insufficient staffing levels. Following our inspection we contacted the fire service and they visited the home.

We found that essential health and safety checks of equipment used to assist people had not been carried out. This put people at risk of harm.

The home did not employ staff for the purpose of organising and facilitating activities for people. The registered manager told us this was the responsibility of care staff. Our observations were that people living at the home were not provided with the opportunity to engage in meaningful activities. We recommend that the provider reviews their training for staff in relation to the delivery of meaningful activities for people living with Dementia.

We looked at the home’s medication policy and found it was robust and gave staff guidance on how to administer people’s medication safely and appropriately. Records we looked at were accurate, medication rooms were clean and tidy and temperatures of both the room and the medication fridges were monitored and recorded.

Recruitment practices were safe and thorough. Staff demonstrated a good understanding of how to protect vulnerable adults. They told us they had attended safeguarding training. Policies and procedures were in place to make sure any unsafe practice was identified and people living at the home were protected. People living at the home told us they felt safe and knew how to report concerns about their safety if they had any.

During our visit we saw people looked well cared for. We observed staff speaking in a caring and respectful manner to people who lived in the home. Staff demonstrated that they knew people’s individual characters, likes and dislikes. People's nutritional needs were met and they had access to a range of health care professionals to maintain their health and well-being.

Care plans were person centred and individually tailored to meet people’s needs. We looked in people’s bedrooms and found people had personalised their rooms with ornaments and photographs.

There were systems in place to ensure complaints and concerns were fully investigated. People who used the service and their relatives were aware of how to report concerns.

The overall rating for this service is 'Inadequate' and the service is therefore in 'special measures'. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider's registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

Full information about CQC's regulatory response to any concerns found during inspections is added to reports after any representations and appeals have been concluded.